Sending Public Health back to the NHS…the comfort of false counsel

Jim McManus is Vice-President of the Association of Directors of Public Health. (www.adph.org.uk) This is his personal view.

Events, dear boy, events

We’ve seen in recent months the call from several sub-sections of the public health world (addictions, sexual health, tobacco control) for their services to be returned to the NHS. To take two examples:

Earlier this month (June 2018) Public Health England published the results of Sexually Transmitted Infection attendences and infections in England. You can read my take on this here https://jimmcmanus.wordpress.com/2018/06/05/a-personal-take-on-the-new-sexual-health-data-release/ . In short, overall the number of STIs was broadly the same as previous years, while at the same time, the number of attendances increased significantly (13%) over five years. From 2.9m in 2013 to 3.3m in 16/17. The number of health screens for chlamydia, gonorrhoea, syphilis and HIV also increased from 1.5m in 2013 to 1.77m in 16/17. The ten year trend in some STIs for gay and MSM has continued. Things aren’t rosy. In fact we’re engaged in one of the biggest modernisation exercises in the history of public health, forced on us by cuts. But the ability to innovate and increase efficiency is nearing its end. Cuts – the £600m cuts to Public Health – have consequences.

Setting media hares running

The significant increase in Sexual Health service attendance has gone largely unrecognised. It was underplayed in the PHE media statement itself. That turned out to be regrettable.

It was further and unhelpfully underplayed in the media coverage and response. In a time of cuts, local authorities have managed a 13% increase in attendances. The media reporting took an increasingly negative tone to the local authority role in sexual health commissioning. A slap in the face to clinicians and commissioners.

Cue calls for a new settlement for sexual health funding. Well, ok. But I’d much rather have a reversal of the Public Health cuts, along with a recognition from government that cutting public health does more harm than good, and it also displaces cost elsewhere in the system (more people get HIV, more people need treatment). What makes Sexual Health or any other bit of what we do special? Why single this out when the rest of the Public Health system has the same sets of pressures?

There’s much more to Public Health than Sexual Health – drug and alcohol, weight management, child health. Though you’d have been hard pressed to see any of that in the media this last week.

Cuts have consequences

Calls for a return of public health to the NHS is the easy option, and a deceptively easy one at that.

This is folly, because the state of the NHS finances make it vanishingly unlikely public health would be protected. And yes I know a few people have solidified the wish that it would be into a toothless promise that it will be. There’s no substance to rely on here.

The conceit that transferring a service back to the NHS with the current pressures on the NHS will result in anything more than the money local government has currently is as fanciful as the £350m for the NHS a week from Brexit. People clearly are prepared to believe both, however, because they’re easy and comforting. And – it turns out – wrong.

Dreams over hard experience

I’ve been around long enough to remember that public health budgets got raided frequently in the NHS, and in frequent winter crises that happened and will happen again as beds and acute pressures rule over all else.

Moreover, the British people largely are in love with the bits of the NHS that fix our broken bits and cure cancers. They’re often not that bothered about some of the other stuff which is equally important in the eyes of professionals. Precious few in most opinion surveys have ever suggested more money goes to the (wrongly) perceived as “self-inflicted” health issues Public Health commissions for. The opposite, in fact.

The idea that CCG board members are overwhelmingly pro-PreP, for example, when they see the costs involved, is simply nonsense. Surely we remember the distasteful statements by NHS England over PreP? Funding prep took money away from children with life-threatening diseases and other treatments was one line much trailed, and it came direct from NHS England. Have we forgotten that?

Sexual health and addiction treatments in some cases in the NHS were wonderful. In many other cases they often only got protected in the NHS because they were wrapped up in global contracts with NHS trusts, and to that extent got forgotten commonly, starved sometimes or developed usually only where there were real commissioner and provider advocates for them. The idea that this was somehow a great system is, frankly, a triumph of rose-tinted nostalgia over hard experience. Remember this from 2010 : there was outrage when the NHS cut HIV and STI services at a time when infections were rising. Those who think a return to the NHS is the answer need to be careful what they wish for.

Still think Public Health is best back in NHS hands?

The myth: Local Authorities are a lottery, NHS was consistent

Then we have the empty argument over the local authority post-transfer postcode lottery. Local Authorities are prioritising, they have to (£600m less money for Public Health alone?) And some of them will prioritise different things based on the needs of their population. That’s life. The idea that the NHS won’t do exactly the same if it got back public health is fanciful, because history shows that is exactly what happened when it did, and what many Directors of Public Health inherited. The NHS in London cut HIV services at a time when HIV was rising because they wanted “resources to be targeted more effectively”, remember.

Some of us when we inherited services couldn’t find contracts. Many of us found the NHS had simply decided not to commission X or Y but hide the responsibility for it in a larger service which didn’t get done.

If we had the same industry of Freedom of Information requests then that we have now on public health, a sorry picture would have emerged over NHS stewardship of some issues.

There are many more arguments I could marshal for why returning Public Health to the NHS is folly, but let me stop at one : we have several national reports that show local government has done a good job in difficult circumstances and has prioritised, as well as innovated. We have had more transparency. For every single case where a local authority has not done well or has done badly with public health, there are more where it has done well.

Public Health is more than a bunch of services

There’s another and much deeper set of arguments for why Public Health should go nowhere near a return to the NHS. And that’s the agenda on wider determinants and social determinants of health. Remember them? The idea that health care is only 15% of your health outcomes. So why should the NHS get all of Public Health when local authorities are THE place to do place-shaping and system leadership. The much vaunted STPs/ICSs (insert new acronym for whichever week you happen to be reading this) are not mostly going to really deliver this because they will get bogged down in NHS system change and care systems. The advent of economic growth, new transport plans (LTP4s) and hundreds of thousands of new homes brings with it major opportunity to build a healthier population which creates less strain on the NHS. Public Health didn’t lead that fully when it was in the NHS. It has the opportunity to now in local government.

The naysayers

Let’s recognize that at the heart of this remains a suspicion that local authorities do not care about Public Health. This is a suspicion not borne out by hard facts in the vast majority of cases, and certainly the same could have been said when we were in the NHS. But that doesn’t stop the naysayers, whose agenda is political about the NHS, not evidence based about outcomes.

There remain a series of vested interests who never wanted public health out of the NHS, and who have always been naysayers to the current system. They argue often by case study or badly crafted reports based on equally badly written FOIs that take spending on this or that service in isolation that it’s all bad, rather than marshaling any convincing national overview.

Let’s take addiction services as an example. Among other things, a BMJ blog arguing for wholesale return to the NHS selectively argues drug-related deaths as a reason for transfer, ignoring much of the work councils do to reduce drug-related deaths, ignoring the national review of drug-related deaths which concluded there were multiple causes; causes which had been increasing since before councils assumed responsibility. The national roll-out of naloxone by councils to reduce opiate deaths was recognised as just one success in reducing drug-related deaths. Without work already done by councils and providers together, drug-related deaths would be even worse.

In 2014 a joint report by Public Health England and the Association of Directors of Public Health saw that, largely, councils were taking their commissioning roles very seriously and were trying to improve quality, outcomes and value for money.

This report was followed by a Public Health England evidence review in 2017, which found English treatment systems were “comparable with or better than other countries’”. These points were all conveniently left out by the BMJ blog because they simply didn’t fit their narrative.

Let’s remember the CQC report looked largely at detoxification services, not the whole of addiction services looked at by the PHE review. A further point conveniently left out by the “returners”.

For a profession that claims to be evidence-based, this kind of selective post hoc justification of ambitions which are essentially political and about getting services back in the NHS for the sake of it is shoddy.

That’s just one example of simplistic ‘council commissioning bad’ rhetoric, which is not borne out by outcomes data. There are many more.

Storing up problems

I agree entirely we need a new settlement on funding . Here’s an idea : how about we alljoin forces and argue that government reverse the cuts or even just stop them? But the more various bits of the public health sub-sectors fragment with a call to send stuff back to the NHS the more it will just make things worse for the rest of Public Health and it won’t improve things for sexual health or anything else.

Yet what we have seen is different little bits of the public health world argue for their bit of the cake without seeing the picture of public health funding as a whole, and thereby fragment any attempt at a united clear narrative – these cuts have consequences for people and the public purse. They were the wrong decision.

The advocacy for “my bit” of the world at the expense of others is storing up problems. It’s letting the fact that the public health cuts have consequences be smoothed over to all our detriment. Some of this has been done through an industry of poorly crafted Freedom of Information Reports resulting in an avalanche of reports that argue “Local Authorities are not spending enough on. insert topic of choice…” All this does is create a fight for who shouts loudest not what is most important in a local area.

While all this is going on, the elephant in the room – £600m of cuts – until very recently, has remained challenged by many fewer agencies than could and should have been the case, because people would rather pursue a protectionist agenda over their own bit of the cake while arguing loudly – and disingenuously – that they care about Public Health. So much for solidarity. This fragmented campaigning makes local authorities the scapegoat for the cuts.

With this unhappy division, the fact that cuts have consequences is something the government which decided it escapes accountability for.

I said in the LGC in January that it’s ” time for a joined-up conversation based around outcomes for people. Knee-jerk calls for moving the deckchairs around because some folk don’t trust councils to do the right thing are a distraction.” I don’t see that anything has changed that need. If anything, it’s more pressing.

Cuts have consequences

Cuts have consequences. The Government continues its agenda of expecting local authorities to do everything in public health and more while removing £600m from the Public Health Budget. Have I said all the current fragmented campaigning does is make local authorities the scapegoat?

Cuts have consequences. It’s time we all got together to make clear that is the case, and that it’s unacceptable.

Cuts have consequences. It may be because one sub section of Public Health shouts louder than another can, that your bit of that world – which isn’t sexy and doesn’t get important figures telling everyone how wonderful you are – bears the brunt of them. Be careful what you wish for.